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enlargement of internal iliac aneurysms treated by simple

proximal ligation is well recorded. Even small aneurysms,

less than 3 cm in diameter,may fail to completely thrombose

after proximal ligation alone (Nakajima et al. 2001). It is

currently accepted that the best open surgical procedure

involves the stitching of the branch vessel ostia from within

the aneurysm sac (endo-aneurysmorrhaphy) as well as

proximal ligation. This operation can be technically difﬁcult,

and carries an appreciable mortality (5–10%) and should

probably bereserved for ﬁt patients with symptoms related to

compression of adjacent structures (Parry et al. 2001).

The endovascular options include placement of a stent-

graft across the internal iliac origin after occlusion of the

outﬂow, packing of the entire aneurysm sac with multiple

thrombogenic coils or occlusion of both the inﬂow and

the outﬂow vessels (Parry et al. 2001; Fahrni et al. 2003;

Tsilimparis et al. 2009).

The simplest method of transcatheter intervention is the

placement ofan appropriatestent-graft, asdescribed abovefor

the common iliac segment, across the internal iliac ostium.

This technique is not dependent onthe presence of a proximal

neck and may be reserved for those cases with little or no

normal artery between the internal iliac ostium and the

aneurysm sac. The internal iliac artery bifurcation is cathe-

terised prior to stent insertion and the anterior and posterior

divisions blocked as proximally as possible with either plati-

numcoils orAmplatzer plugs(Fig. 7). Thismeans thatthe coil

diameter must becarefully chosento beoversized by1–2 mm

in order toavoid distal extension andbranch vessel occlusion.

The use ofﬂuid embolic materialin these circumstancesis not

advisable because of the risk of severe pelvic ischaemia and

potential damage to sensitive adjacent organs and nerves.

Where there is a well deﬁned ‘proximal neck’ of internal

iliac main-stem leading into the aneurysm and suitable exit

Fig. 6 a This CTA shows a

5cmleft internal iliac aneurysm

and a small right internal iliac

aneurysm. b The 3D

reconstruction shows that there is

also a 2.8 cm aneurysm of the left

common iliac artery. c A10mm

Amplatzer plug has been placed

in the posterior division of the

left internal iliac and the tip of the

contralateral 6F sheath has been

placed in the origin of the left

anterior division prior to

deployment of a 12 mm plug

which will extrude into the main

trunk after release. d Deployment

of an Endurant stent-graft limb

(Medtronic) between the

proximal left common and

external iliac segments has

excluded both left iliac

aneurysms. There is no

backﬁlling via the plugged

internal iliac artery and the 4

radio-opaque markers are visible

on the two plugs

174 R. Jackson and J. Rose

https://t.me/med1917

vessels in terms of an anterior and a posterior divisional

branch, then selective occlusion of inﬂow and outﬂow

vessels will sufﬁce. Appropriately oversized platinum coils

or plugs are used to block the internal iliac artery bifurca-

tion, taking care not to encroach on the distal branch ves-

sels. The ostium of the vessel is then plugged (Fig 7c).

If the aneurysm is large and complex with multiple small

outﬂow branches, it may prove impossible to safely occlude

these outﬂow vessels individually. In such cases it may be

possible to pack the aneurysm sac completely with a mixture

of coils, generally starting with larger coils and ﬁlling in the

residual spaces with medium and small coils. In exceptional

cases thrombin may be injected through the same catheter in

order to produce a more complete thrombotic effect. As an

alternative, Onyx may be used in the same manner as for

visceral artery aneurysms (described above in Sect. 2).

3.4.3 External Iliac Aneurysms

The external iliac segment is very rarely involved by ath-

eromatous aortoiliac aneurysms and is only occasionally

found as the site of an isolated iliac aneurysm. In general,

as for common iliac lesions, the endovascular treatment

consists of stent-graft insertion. Where there is no suitable

proximal neck in the external iliac, the proximal end of the

stent-graft may be placed in the common iliac.

Fig. 7 a An isolated, right internal iliac aneurysm was selectively

catheterised via a left femoral approach and a coil bundle created in the

distal trunk. b The aneurysm had a very short proximal neck and this

image shows a 12 mm Amplatzer plug immediately after deployment

in the ostium of the internal iliac. c Follow-up CTA at 6 months

conﬁrmed complete exclusion of the internal iliac aneurysm sac. The

lower end of the Amplatzer plug is visible in the anterior sac.

Subsequent annual ultrasound follow-up has remained satisfactory

Fig. 8 a, b There is a 17 mm

false aneurysm arising from the

left brachial artery. c, d Under US

guidance a 21-G needle is

positioned within the false

aneurysm and thrombin injected

leading to immediate almost

complete thrombosis

Endovascular Repair of Iliac, Visceral and False Aneurysms 175

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4 Femoral False Aneurysms

Requests to examine a painful expansile swelling in the groin

following femoral artery catheterisation are an extremely

familiar scenario in all ultrasound departments within hos-

pitals that provide an interventional vascular or cardiology

service. The diagnosis and subsequent management of

peripheral falseaneurysmshas beentaken overcompletely by

the radiologist during the last decade. In addition to ultra-

sound-guided compression, all the techniques described

previously inthis chapterhave beenused totreat femoralfalse

aneurysms. Without doubt, however, percutaneous thrombin

injection has been shown to be the quickest, most pain-free

and effective treatment. Success rates of over 90% are to be

expected with a single injection and complications are rare

(Morgan and Belli 2003; Hanson et al. 2008).

In most institutions thrombin injection is now the treat-

ment of choice for stable false aneurysms, which have failed

to resolve after 48 h of observation. Human thrombin

(Tisseel, Baxter, Glendale, CA, USA) is used at low doses,

usually less than 500 IU. Balloon protection is no longer

used. While femoral false aneurysms are by far the most

commonly encountered, other sites have also been treated

with percutaneous thrombin (Fig. 8).

5 Conclusion

This chapter has focussed on endovascular treatment for a

variety of aneurysms. Visceral and isolated iliac aneurysms

are relatively uncommon, but with the exception of common

iliac aneurysms they can be very challenging to treat by open

surgical methods. Although their incidence makes it highly

unlikely that ﬁrm evidence will ever be available from

randomised studies, it is clear that a variety of endovascular

therapies are now available which provide successful treat-

ment, at least in the medium term, while avoiding the

potential complications of difﬁcult surgery. The use of

ultrasound compression and more recently percutaneous

thrombin injection has been a revolution in the management

of femoral, and other, false aneurysms occurring after

catheterisation, so that few of these patients now need to be

managed with open surgery.

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Endovascular Repair of Iliac, Visceral and False Aneurysms 177

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Dialysis Access Management

J. R. Asquith

Contents

1 Introduction.......................................................................... 179

2 Dialysis Line Insertion and Management......................... 179

2.1 Dialysis Line Insertion .......................................................... 179

2.2 Choice of Vein for Access: Conventional Central Veins.... 180

2.3 Optimal Catheter Position..................................................... 180

2.4 Alternative Dialysis Line Access Routes ............................. 180

2.5 Fibrin Sheath Formation ....................................................... 180

2.6 Catheter Repositioning .......................................................... 181

3 Management of Dialysis Fistulae and Grafts................... 182

3.1 Imaging of Dialysis Fistulae and Grafts............................... 182

3.2 Angioplasty of Dialysis Fistulae and Grafts ........................ 182

3.3 Angioplasty of Resistant Stenoses........................................ 183

3.4 Stenting of Dialysis Fistulae and Grafts............................... 183

3.5 Central Venous Stenosis in Dialysis Patients....................... 184

3.6 Management of Thrombosed Dialysis

Grafts and Fistulae ................................................................ 184

3.7 Complications of Dialysis Fistula

and Graft Interventions ......................................................... 186

4 Conclusion ............................................................................ 186

References...................................................................................... 186

Abstract

The long-term maintenance of haemodialysis access via

funnelled lines or ﬁstulas is challenging. The insertion

of dialysis lines and the management of subsequent

complications of these catheters by interventional radiol-

ogy will be discussed. A range of endovascular techniques

for the presentation of haemodialysis ﬁstula access will

also be reviewed.

1 Introduction

The aim of this chapter is to review the prominent role of

the interventional radiologist in the multidisciplinary man-

agement of haemodialysis vascularaccess. This encompasses

the placement and management of haemodialysis catheters

and a range of percutaneous procedures to deal with the

complications of grafts and ﬁstulae. The interventional radi-

ologist is anintegralpart of thedialysis team withan ability to

provide signiﬁcant beneﬁts in preserving vascular access.

2 Dialysis Line Insertion

and Management

2.1 Dialysis Line Insertion

Temporary, non-tunnelled haemodialysis catheters are for

short-term haemodialysis, which is between several days

and a few weeks, duration. Short-term haemodialysis line

insertion has a low complication rate and is usually carried

out by non-radiologists.

Long-term haemodialysis catheters are tunnelled through

a short subcutaneous route between the skin and the site of

venous puncture. Tunnelled dialysis lines are recommended

by the American National Kidney Foundation clinical

guidelines (National Kidney Foundation 2001) in patients

requiring temporary venous access for periods greater than

J. R. Asquith (&)

University Hospital of North Staffordshire NHS Trust,

Newcastle Road, Stoke-on-Trent, ST4 6QG, UK

e-mail: john.asquith@uhns.nhs.uk

M. G. Cowling (ed.), Vascular Interventional Radiology, Medical Radiology. Diagnostic Imaging,

DOI: 10.1007/174_2012_567, Ó Springer-Verlag Berlin Heidelberg 2012

179

https://t.me/med1917

3 weeks. At the skin exit site of tunnelled lines a cuff

reduces infection rates and decreases the inadvertent

removal of tunnelled catheters compared to non-tunnelled

catheters (Flowers et al. 1989; Maki et al. 1988).

Tunnelled lines can provide good haemodialysis access for

many months. They are particularly useful during the matu-

ration of a ﬁstula or graft, which may take up to 3 months

before dialysis is possible. Tunnelled catheters are also used

‘permanently’ when all other access routes for ﬁstula forma-

tion have been exhausted. In addition many patients present

late to renal units with end-stage renal failure and hence tun-

nelled catheters are often required until deﬁnitive dialysis

access is available (Chesser and Baker 1997). The disadvan-

tages of tunnelled lines compared to native ﬁstulae include the

risk of infection, development ofvenous stenosis or occlusion,

which is often central, and the presence of the external lines.

Traditionally tunnelled dialysis lines were inserted

without imaging guidance. However, line placement using

ultrasound and ﬂuoroscopy has been shown to produce

better results than using anatomical landmarks alone.

Ultrasound provides a greater puncture success rate with

fewer complications than blind insertion (Mallory et al.

1990; Lameris et al. 1990; Forauer and Glockner 2000).

Published series show lower rates of primary line malpo-

sition, fewer complications and less catheter infections with

radiological placement when compared to blind insertion

(McBride et al. 1997; Trerotola et al. 1997).

There are numeroustypesof tunnelled dialysiscatheters in

use. They include the Tesio system of two separate single-

lumen 10F silastic catheters, which produce higher ﬂow

rates than the older dual lumen step-tip designs of catheters

(Prabhu et al. 1997). The main disadvantage of Tesio lines is

the requirement for two separate tunnels (Tesio et al. 1994).

It was initially anticipated that twin catheters would have a

longer survival rate than the dual lumen devices, but there is

evidence that this is not the case (Caridi et al. 1999). An

alternative is the Ash Split 14.5 F catheter which has two

independent lumens and hence the theoretical advantages of

twin catheters,butonly requiresa singlesubcutaneous tunnel.

2.2 Choice of Vein for Access: Conventional

Central Veins

There are several venous access sites for tunnelled line

insertion including the internal jugular and subclavian veins.

Subclavian lines have a higher incidence of procedural

complications when compared to internal jugular lines,

including subsequent venous thrombosis and stenosis

(Cimochowski etal. 1990;Schillinger et al. 1991;Macdonald

et al. 2000; Trerotola et al. 2000). With subclavian line-

induced venous stenosis thereis also thepossible exclusion of

use of the ipsilateral extremity for future ﬁstula formation.

Therefore, the subclavian approach should be avoided

wherever possible. The right internal jugular vein should be

used preferentially, followed by the left internal jugular vein.

This is because right-sided insertion is technically more

straightforward and right-sided internal jugular venous

catheters cause stenosis less frequently than left-sided cath-

eters (Salgadoet al. 2004).The internal jugular vein puncture

should be low in the neck (approximately 2 cm above the

clavicle), which facilitates tunnelling by avoiding the ster-

nocleidomastoid muscle (Silberzweig and Mitty 1998) and

reduces the risk of kinking due to formation ofan acute angle

in the line which can be associated with higher punctures.

2.3 Optimal Catheter Position

The optimal position for the tip of a dialysis catheter is in

the region of the superior vena cava-right atrial junction

(National Kidney Foundation 2001). If the catheter is

positioned too low in the right atrium there is the risk of

perforation of the right atrial wall and arrhythmias. During

catheter positioning it is also important to realise that due to

traction on the catheter in the subcutaneous tissues the tip of

the catheter will move cephalad by approximately 3 cm

when the patient moves from the supine to the upright

position (Nazarian et al. 1997; Kowalski et al. 1997).

A routine, post procedural chest radiograph is not required

for lines inserted using imaging guidance because malpo-

sition and complications are rare (Gladwin et al. 1999;

Chang et al. 1998).

2.4 Alternative Dialysis Line Access Routes

Alternative routes have been described for when both the

internal jugular and subclavian veins are unavailable for

line insertion. These approaches include femoral veins,

neck collaterals (Funaki et al. 2001), external jugular veins

(Forauer et al. 2000), the translumbar inferior vena cava

(Markowitz et al. 1998; Rajan et al. 1998) and percutaneous

hepatic veins (Po et al. 1994; Duncan et al. 1995). The

femoral vein has a slightly higher risk of infection (Zaleski

et al. 1999) and a substantially shorter primary catheter

patency rate when compared to the internal jugular veins

(Maya and Allon 2005). A further potentially useful tech-

nique is venous recanalization of occluded veins for central

venous catheter placement (Funaki et al. 2001; Haller et al.

2009). When recanalization of central veins using conven-

tional techniques fails, then ‘sharp’ recanalization has been

described as an alternative. Sharp recanalization uses the

stiff end of an hydrophilic wire or an intravascular needle to

traverse the occlusion and hence allow insertion of the

dialysis catheter (Athreya et al. 2009).

180 J. R. Asquith

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2.5 Fibrin Sheath Formation

Dialysis lines usually fail due to the formation of a peri-

catheter ﬁbrin sheath or intracatheter thrombosis (Crain

et al. 1996; Trerotola et al. 1997). The clinical signs of ﬁbrin

sheath formation include poor ﬂow and an inability to

aspirate blood through the catheter. A ﬁbrin sheath can be

detected by performing a linogram, which will demonstrate

contrast being retained around the tip of the line and

backtracking around it (Fig. 1a).

The treatment options for ﬁbrin sheath formation include

thrombolytic infusions, line stripping, catheter exchange or

line replacement. Stripping of a ﬁbrin sheath is performed

by capturing the end of the dialysis line with a gooseneck

snare and repeatedly pulling the tightened snare down over

the end of the line to remove the ﬁbrin (Fig. 1) (Crain et al.

1996). Findings from a randomised study show that line

stripping and urokinase infusion are equivalent in immedi-

ate restoration of catheter function and maintenance of

long-term patency (Gray et al. 2000). This study would

suggest that thrombolytic infusion is preferable to stripping

because it is non-invasive, cheaper to perform, administered

on the dialysis unit, preferred by patients and safer. Another

randomised trial has shown longer patency rates with line

exchange compared to stripping for the treatment of ﬁbrin

sheath formation (Merport et al. 2000). However, when

retrospectively compared by another centre (Janne d’Othee

et al. 2006) durability of catheter function was equivalent

between the techniques of line stripping and line exchange.

Therefore, it is clear that catheter exchange or line stripping

should be reserved for those patients in whom thrombolytic

infusions have failed. With conﬂicting evidence when

deciding on whether to strip or exchange a failing line, then

consideration regarding cost and patient preference should

also be made.

2.6 Catheter Repositioning

The radiologist can assist in repositioning catheters that

have become misplaced into the contralateral brachioce-

phalic vein due to either spontaneous migration of the

catheter tip or primary misplacement during insertion

without ﬂuoroscopic guidance. A transfemoral approach is

usually used to reposition central lines. The repositioning is

performed by dragging the line down with a pigtail catheter

or by grabbing the tip of the line with a gooseneck snare

(Hartnell et al. 1996; Boardman and Hughes 1998).

Radiological repositioning of lines is quick, simple to per-

form and avoids replacement of the line.

Fig. 1 a Twin Tesio catheters placed via a left common femoral vein

approach. Linogram shows contrast is retained around the catheters

due to ﬁbrin sheath formation (arrow). Urokinase infusion produced

no improvement; b line stripping was performed using a gooseneck

type snare with a left internal jugular vein approach; c the ﬁnal image

shows contrast ﬂowing freely from the catheter side holes

Dialysis Access Management 181

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3 Management of Dialysis Fistulae

and Grafts

3.1 Imaging of Dialysis Fistulae and Grafts

The commonest indications for ﬁstula and graft imaging are

poor ﬂows, high venous pressures during dialysis and fail-

ure to mature. The main imaging investigations are Doppler

ultrasound and digital subtraction angiography (DSA). DSA

remains the mainstay of ﬁstula imaging, because it is quick,

easy to perform, depicts the entire length of the venous

return and can be followed immediately by an interven-

tional procedure. However, ultrasound plays an important

initial role in assessing problematic ﬁstulae and allows

planning of the more invasive investigation of DSA.

Comparative studies have shown that Doppler ultrasound

and DSA correlate well (Chandra et al. 2010).

The optimal approach for performing a diagnostic ﬁs-

tulogram depends upon the clinical indication. When there

is delayed maturation the arterial inﬂow and the arteriove-

nous anastomosis should be studied and this can be per-

formed by retrograde puncture of the ipsilateral brachial

artery at the elbow. When there is hand ischaemia due to

steal syndrome, then subclavian arterial catheterisation from

the femoral route allows complete visualisation of the upper

limb arteries and the entire venous outﬂow. If the indication

is poor ﬂows or high venous pressures, then a retrograde

puncture of the venous side of the ﬁstula allows demon-

stration of the arteriovenous anastomosis and the entire

length of the venous return..

Pullback pressure gradient measurement from the SVC

to the arterial anastomosis may be helpful when no signif-

icant stenosis is identiﬁed on the angiogram despite

abnormality with dialysis. Pressure measurements may also

be useful as an adjunct to angiography for identifying

venous stenoses persisting after apparently successful

angioplasty (Funaki et al. 2002).

Carbon dioxide gas has been used as an alternative to

iodinated contrast for angiography of the venous side of a

ﬁstula. This is particularly useful in patients who have not

yet used their ﬁstula for dialysis and where avoidance of

nephrotoxic contrast is desirable in an effort to preserve

residual renal function. However, carbon dioxide must be

used with caution due to the risk of reﬂux into the cerebral

circulation when being used to study the arterial anasto-

mosis (Ehrman et al. 1994; Spinosa et al. 1998; Kariya et al.

2010). Gadolinium has also been used as an alternative to

iodinated contrast for catheter ﬁstulagrams (Spinosa et al.

1998; Sancak et al. 2002) and contrast enhanced MRA has

been used as an alternative to invasive ﬁstulography.

However the risk of nephrogenic systemic ﬁbrosis has now

largely prevented these applications.

Doppler ultrasound is an accurate technique for the

detection of problems in ﬁstulae and grafts (Finlay et al.

1993; Bacchini et al. 2000). A major limitation with ultra-

sound is the difﬁculty in detecting central venous stenoses.

Doppler ultrasound has also been successfully used as a

guide to angioplasty and stenting in arterio-venous access in

order to avoid nephrotoxic contrast. This technique is par-

ticularly useful in patients not yet on dialysis or in those

who are allergic to contrast media (Marks et al. 2007).

3.2 Angioplasty of Dialysis Fistulae

and Grafts

The ﬁrst radiological reports of angioplasty in grafts and

native ﬁstulae were published in the early 1980s (Gordon

et al. 1982; Hunter et al. 1984). Currently, dilation of

stenoses greater than 50% with an associated clinical or

haemodynamic abnormality is recommended by the clinical

practice guidelines of the American National Kidney

Foundation (National Kidney Foundation 2001). Angio-

plasty of these signiﬁcant stenoses reduces the thrombosis

risk and increases the longevity of the access (Turmel-

Rodrigues et al. 2000a; Manninen et al. 2001). Angioplasty

has a low complication rate, may be performed on an out-

patient basis and dialysis can resume immediately.

An antegrade approach should be used for stenoses

located away from the arterial anastomosis and a retrograde

approach for stenoses close to the arterial anastomosis. The

diameter of the angioplasty balloon should be equal to or

1 mm greater than the diameter of the adjacent normal

vessel or graft. Unless the vessel is unusually small then 6 to

8 mm diameter balloons are used in both grafts and native

ﬁstulae. It has been shown that 55% of stenoses require

pressures greater than 15 atmospheres to eliminate the waist

on the balloon. Very high angioplasty pressures of greater

than 20 atmospheres are needed to adequately treat 20% of

stenoses in native ﬁstulae and 9% in grafts (Trerotola et al.

2005).

Stenoses frequently recur relatively rapidly and patency

rates depend on the type of access being treated and

on the location of the stenosis. Technical success for angio-

plasty is usually deﬁned as a less than 30% residual diameter

stenosis. Several series for angioplasty in native upper limb

ﬁstulae have shown a very good technical success rate of

90–97%. However, currently the Achilles heel of ﬁstula

angioplasty is restenosis with a 12-month primary patency of

26–64%. With further intervention a secondary patency rate

of 81–90% can be achieved at 1 year (Lay et al. 1998;

Turmel-rodrigues et al. 2000a; Manninen et al. 2001; Clark

et al. 2002; Maeda et al. 2005; Asif et al. 2006). Similarly,

several large series in grafts show angioplasty has a high

clinical success rate of up to 98%, but with a primary patency

182 J. R. Asquith

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rate of 17–44% at 1 year. After a year secondary patency

rates of 92% can be achieved in grafts (Kanterman et al.

1995; Aruny et al. 1999; Beathard 1992; Safa et al. 1996).

As a result of the disappointing results of restenosis after

angioplasty in ﬁstulae there has been some enthusiasm for

the potential beneﬁt of drug-eluting balloons in order to

reduce ﬁstula restenosis rates. This has followed on from

the promising early experience in lower limb arteries

(Werk et al. 2008; Tepe et al. 2008; Schmidt et al. 2011).

Paclitaxel eluting balloons may help to inhibit neo-intimal

hyperplasia and hence reduce the re-stenosis rates. How-

ever, the role of drug eluting balloons needs to be further

investigated with randomised trials.

3.3 Angioplasty of Resistant Stenoses

Some ﬁstula and graft stenoses are resistant to balloon

angioplasty using standard pressure balloons. These resis-

tant lesions have been treated with high pressure balloons,

for example, the Bard Conquest balloon that has a rated

burst pressure of 30 atm. Use of the Conquest balloon, with

ultra high pressures of up to 40 atm, has also been advo-

cated (Trerotola et al. 2004). With these very high pressures

a high technical success rate of 100% was achieved, which

is comparable to cutting balloon angioplasty.

Use of the cutting balloon to treat resistant haemodialysis

stenoses was ﬁrst described in the mid 1990s (Vorwerk

et al. 1995a, 1996a). The blades of a cutting balloon produce

microincisions allowing controlled intimal disruption

(Fig. 2). Cutting balloons can achieve high technical success

rates of 95–100% in treating resistant stenoses in ﬁstulae and

grafts (Vorwerk et al 1996a; Song et al. 2004; Bhat et al.

2007). In the series by Song et al. there were 2 ruptures in 8

cases of native ﬁstulae, but one of these was located

at the cephalic arch, which is notorious for complications

(Turmel-Rodrigues et al. 2000a). In a recent, but relatively

small, randomised trial of cutting balloon angioplasty versus

ultrahigh-pressure angioplasty in native ﬁstulae the two

techniques had equivalent immediate results (Kundu et al.

2010). A second, but retrospective, comparative study of

cutting balloon versus high-pressure balloon used in native

ﬁstulae to treat stenoses resistant to conventional angioplasty

showed that both techniques were effective. In the cutting

balloon group there was some evidence of a more long-

standing primary patency rate at 6 month follow-up (Wu

et al. 2008). In summary, current evidence suggests that

cutting balloons may play an important role in treating

resistant stenoses, but there is only limited information

regarding long-term patency rates, safety and cost effective-

ness when compared to ultra high pressure balloons.

3.4 Stenting of Dialysis Fistulae and Grafts

There has been considerable interest in the stenting of ﬁs-

tulae and grafts, but randomised trials have not shown

signiﬁcant advantages of bare-stents over angioplasty in

Fig. 2 a The arterial

anastomosis of this forearm loop

graft has already been

unsuccessfully angioplastied

using a conventional balloon.

Cutting balloon angioplasty was

therefore performed to treat the

resistant stenosis (arrow); b the

ﬁnal ﬁstulagram after cutting

balloon angioplasty shows no

residual stenosis

Dialysis Access Management 183

https://t.me/med1917

recurrent venous stenosis (Hoffer et al. 1997; Quinn et al.

1995; Beathard 1993). Primary patency rates of only 47

and 20% at 6 months and 1 year, respectively were obtained

in one study for a small subgroup of native ﬁstulae

(Turmel-Rodrigues et al. 1997a). Most studies with stenting

suggest the need for close follow-up and multiple secondary

interventions to maintain patency. Therefore, in native ﬁstu-

lae, stents are generally only used selectively to treat com-

plications and when angioplasty fails to maintain patency,

particularly in patients who are unsuitable for surgical revi-

sion (Turmel-Rodrigues et al. 1997a; Pan et al. 2004).

The situation is different for prosthetic haemodialysis

grafts. A recent prospective randomised trial (Haskal et al.

2010) has shown greater patency rates for the treatment of

venous anastomotic stenoses with the use of stent grafts

compared to conventional balloon angioplasty.

Covered stents have also been advocated for the treat-

ment of pseudoaneurysms of dialysis access grafts and ﬁs-

tulae (Fig. 3). A large pseudoaneurysm can cause difﬁculty

with needling and be unsightly for the patient. Traditionally,

large pseudoaneurysms have been dealt with surgically.

Small series have been published in which covered stents

have salvaged dialysis grafts and ﬁstulae (Ryan et al. 2003;

Hausegger et al. 1998). In these reports concern about

pseudoaneurysm recurrence and infection have divided

opinion as to whether the stent can subsequently be needled.

3.5 Central Venous Stenosis in Dialysis

Patients

Haemodialysis patients are at particular risk for the devel-

opment of central venous stenosis or thrombosis and much

of this is due to multiple central venous catheterisations

(Cimochowski et al. 1990). Central venous stenoses are

associated with clinical symptoms such as arm swelling

or functional impairment of haemodialysis. Central veins

respond relatively poorly to angioplasty with a 23–29%

primary patency rate at 6 months (Beathard 1992; Quinn

et al. 1995). Published data and opinion regarding stenting

of central venous stenosis are divided. Some authors rec-

ommend stents in central veins (Mickley et al. 1997; Haage

et al. 1999; Vorwerk et al. 1995b) whereas others claim no

advantage of stenting over angioplasty (Quinn et al. 1995;

Bakken et al. 2007). Stent placement for central venous

stenosis refractory to angioplasty has excellent initial

technical results (Fig. 4), but variable 1-year primary

patency rates ranging from 25 to 70% (Haage et al. 1999;

Vesely et al. 1997; Mickley et al. 1997). In the subclavian

vein there is concern about early stent failure caused by

positional compression, which can result in stent fracture

(Maleux et al. 1998; Maintz et al. 2001). More encourag-

ingly, a retrospective study (Vogel and Parise 2004) sug-

gests that nitinol stents can be used in central venous

stenoses with improved patency rates. If a stent is used it

should not overlap and hence exclude adjacent veins from

future access use. In summary, angioplasty should be the

preferred treatment in central venous stenosis with stent

placement reserved for failed angioplasty or recurrence of a

stenosis within a 3-month period (Aruny et al. 1999). It is

also clear that multiple additional interventions are required

to maintain patency with either angioplasty or stenting for

central venous stenoses. Larger randomised studies are still

needed to clarify the role of stents, particularly with the

newer nitinol stents.

3.6 Management of Thrombosed Dialysis

Grafts and Fistulae

Acute graft or native ﬁstula thrombosis should ideally be

avoided by use of screening. Monitoring with ﬂow mea-

surements, clinical examination or Doppler ultrasound can

help by allowing the earlier detection and angioplasty of

Fig. 3 a The arterial and venous sides of this forearm loop graft developed large false aneurysms at the needling sites; b both false aneurysms

were successfully excluded using Viabahn stent grafts (Gore, Flagstaff, CA)

184 J. R. Asquith

https://t.me/med1917

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